HomeMy WebLinkAboutWA Res 25-18 Awarding Box Insurance Property Casualty Insurance ContractResolution WA 25-18
Page 3 of 3
Exhibit “A”
Recommended Bid
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Westlake Academy – FY 25/26 Comprehensive Insurance RFP Page 2 of 39
TABLE OF CONTENTS
Table of Contents .……………………………………………………………. 2
Acknowledgement of Receipt ......…………..………………………... .......... 3
Questionnaire .………………………………………………………….. ........ . 4
General Requirements and Instructions .……………………………. ........ 5
Policy Requirements and Limits ...……………………………………......... 8
Property Insurance, Fire and Extended Equipment Coverage ... ....... 8
General Liability, EPLI, EBLI, ELLI, D&O Insurance .…….…….. ....... 10
Automobile and Physical Damage Insurance ………………..….. ....... 13
Umbrella Liability Insurance ……………………………………….. ....... 15
Crime Insurance ………………..…………………………………… ....... 17
Workers Compensation Insurance.…..……………………………. ...... 19
International Travel Insurance ..…………..………………………......... 21
Student Accident Insurance....…...………..……………………….. ...... 23
Cyber Liability Insurance …………………………………………… ...... 25
Proposal Submittal Format.……………………………………………......... 27
Exhibit “A” - Property Schedule……………………………………….. ........ 28
Felony Conviction Notice Form.………………………………………. ........ 29
Non-Collusion Statement.………………………………………………........ 30
Conflict of Interest Questionnaire ….…………………………………......... 31
W-9 Form ..……………………………………………………………............ 33
Form 2270 ..…………………………………………………………….. ........ 39
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ACKNOWLEDGEMENT OF RECEIPT
THIS FORM MUST BE COMPLETED AND RETURNED PRIOR TO THE SUBMISSION OF ANY BID
FOR THIS REQUEST FOR PROPOSAL.
Please fill in the requested information below as acknowledgement that you have received the Request for
Proposal noted above. If your firm is interested in participating, please complete pages three and four (3
and 4) and return by email by April 25, 2025 to:
Sandy M. Garza
Town of Westlake / Westlake Academy
sgarza@westlaketx.gov
Name of Firm: _________________________________________________
Address: ______________________________________________________
City/State/Zip: _________________________________________________
Phone: (_____) _______________________Fax: (_____)_______________
E-Mail: _______________________________________________________
Name: (Print) __________________________________________________
Title: _________________________________________________________
Signature: _________________________________________ Date: ________
_______Yes, our company does have an interest in responding. 4
4/24/25
Box Insurance Agency
1200 S Main St Suite 1600
Grapevine TX 76051
817-865-1806
adam@boxinsurance.com
Adam Syswerda
President
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Westlake Academy – FY 25/26 Comprehensive Insurance RFP Page 4 of 39
QUESTIONNAIRE
1. Who will have primary responsibility for Westlake Academy’s account?
__________________________________________________________________________
a. Number of years in the insurance business: ___________________________________
b. Insurance background: ____________________________________________________
_____________________________________________________________________
c. Number of schools or public entities serviced: __________________________________
2. Who will be the back-up person for Westlake Academy’s account?
_____________________________________________________________________
a. Number of years in the insurance business: ___________________________________
b. Insurance background: ___________________________________________________
__________________________________________________________________________
c. Number of schools or public entities serviced: __________________________________
4. Westlake Academy will expect the following annual reports from its agents:
a) Summary of premiums and losses by coverage.
b) Forecast of insurance market status prior to renewal.
c) Insurance policy abstracts (summaries).
d) Prior to future renewals, report containing suggested coverage or rating enhancements for the
upcoming year.
e) Following future renewals, a report detailing all material policy changes.
f) Risk management services.
5. Please attach a copy of the following documents:
a) A copy of the current license.
b) A certificate for agent’s error and omission coverage insured for at least $1 million limit.
Dustin Parker
CEO, Box Insurance Agency
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Adam Syswerda
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President Box Insurance Agency
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GENERAL REQUIREMENTS AND INSTRUCTIONS
A. INFORMATION
1. The information contained in these specifications is confidential and is to be used only in connection
with preparing a proposal for the following insurance services or insurance coverages:
Commercial Property – Fire & Extended Coverage
Commercial General Liability
School Professional Liability
Auto Liability & Physical Damage
Workers’ Compensation
Commercial Umbrella Liability
Crime
International Travel Liability
Student Accident Liability
Cyber Liability
2. The effective dates of the policy period for all proposals will be from July 1, 2025 through June
30, 2026.
3. Westlake Academy reserves the right to accept or reject all or any part of the proposals, waive minor
technicalities, and award the proposal to best serve the interest of the Academy. The Academy also
reserves the right to waive or dispense with any of the formalities contained herein.
3. Proposals are to be submitted on the basis of the specifications contained herein. Alternate proposals
will also be considered, provided the alternatives are clearly explained. All deviations from the
specifications must be clearly identified and explained.
4. The information contained in these specifications is to be basis for proposal responses. After receipt
of proposal, additional information needed may be requested via e-mail at: sgarza@westlaketx.gov.
5. The information contained herein is believed to be accurate and up to date but is not intended to be
an express or implied warranty.
6. No telephone, or fax, or e-mailed proposals will be accepted. Proposals may only be accepted if
delivered by email to sgarza@westlaketx.gov .
7. Vendors are cordially invited view the opening of received proposals but are not required to attend. A
link will be posted on the Town of Westlake Bidding page no later than April 11, 2025. Advertisements
will be posted for two (2) weeks in the Town’s newspaper of record (Fort Worth Star-Telegram) on
April 13, 2025 and April 20, 2025.
B. LEGAL
1. All parties submitting proposals are expected to comply with federal, state and local insurance laws
and regulations relative to the preparation and submissions of insurance proposals. Specifically, the
services to be provided are expected to be in compliance with the Americans with Disabilities Act
(ADA), insurance laws and insurance regulations. All proposals that are submitted will be presumed
to be in compliance with all applicable laws.
C. COMMUNICATION
1. Proposals should reference “RFP 25-001 – Westlake Academy Property & Liability Insurance”.
Proposer is required to provide an electronic copy of proposals to:
Sandy M. Garza
Westlake Academy
sgarza@westlaketx.gov
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2. Alternatively, Proposers may to provide a paper (printed) copy of proposals by the deadline to:
Sandy M. Garza
Westlake Academy
1500 Solana Boulevard, Bldg. 7, Ste. 7200 • Westlake, Texas 76262
D.COMMUNICATION WITH TOWN OF WESTLAKE/WESTLAKE ACADEMY MEMBERS
Companies submitting proposals shall not discuss this RFP with employees of the Town of Westlake,
Westlake Academy or members of the Town Council/Board of Trustees. If discussion is necessary, your
company will be notified in writing. Failure to abide by this requirement may result in automatic
disqualification.
E.TIME FRAME
1.The RFP package will be available for download from our website at https://www.westlake-
tx.org/256/Bids-Proposals. Vendors WILL NOT be notified of additional information/addenda
postings. It is the vendor’s responsibility to view the web page regularly, or prior to submitting a
proposal response, to ensure that no addenda or additional information have been issued for the
solicitation.
2.Proposals: must be delivered electronically via email to sgarza@westlaketx.gov , or a printed copy
of proposal to 1500 Solana Boulevard, Bldg. 7, Ste. 7200 • Westlake, Texas 76262 by the deadline
no later than 12:00 p.m., Friday, May 23, 2025.
3.The parties submitting the selected proposals will be notified by June 2, 2025 of the Academy’s
decision.
4.The effective date for proposals is July 1, 2025.
5.Policies or coverage documents are to be provided to the Academy by June 30, 2025. The Academy
reserves the right to not pay any premium until valid policies or coverage documents are received.
F.PROPOSALS
1.Proposals must be clearly explained and identified. All costs, including optional programs, must be
clearly separated and summarized. Exceptions to or deviations from the specifications must be
explicitly identified.
2.Each party submitting a proposal is asked to screen their designated proposals for correctness and
compliance with the specifications.
3.The contents of the proposals shall be kept confidential during the process of review.
G.DISQUALIFICATION AND REJECTION OF PROPOSALS
1.Failure to comply with the requirements or the procedures set forth herein, or to satisfy the insurance
and servicing criteria as set forth in the specifications, may result in disqualification. It is not intended
that these exceptions to the specifications will, in and of themselves, result in disqualification.
H.SELECTION OF VENDOR
1.Westlake Academy reserves the right to reject any or all of the proposals, in whole or in part; to waive
any informality in any proposal, and to accept the proposal which, in its discretion, is in the best
interest of the Academy. An Academy insurance consultant may review proposals for completeness
and for compliance with bid specifications. Proposals will be carefully evaluated for cost effectiveness,
for coverage provisions, and for compliance with the coverage and servicing criteria contained in the
specifications and in accordance with Texas Education Code 44.031 and any other pertinent laws.
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2.The contract will be awarded to the responsible vendor who submits a superior but economical
proposal based on the relative importance of the following selection criteria:
Selection Criteria Maximum Points
Coverage 35
Cost 35
Professional Qualifications 15
Service 15
Total 100
I. TERMS OF AGREEMENTS
1. Westlake Academy desires to receive proposals for a twelve (12) month period, beginning on July 1,
2025 through June 30, 2026.
2.Westlake Academy reserves the right to terminate the agreement at the expiration of the budget
period, during the term of the agreement or at the end of the anniversary date with a sixty (60) day
notice. The agreement will be for current revenues only in accordance with Local Government Code
Section 271.903 to terminate the agreement.
3. The agreement is to contain a cancellation provision that provides for a sixty (60) day notice of
cancellation (except for non-payment) and sixty (60) days e for non-renewal or material change.
J. QUALIFICATION OF INSURERS
1. Insurance companies must have a general policyholder’s rating of A- VII or better as published by
A.M. Best Company in the latest edition of its Key Rating Guide. Insurers shall be duly licensed and
comply with all applicable insurance laws and requirements of the Texas State Board of Insurance.
2.Proposals will be accepted for intergovernmental risk sharing pools organized in accordance with
article 4413(32c), Texas Interlocal Cooperation Act. Self-insured pools must include a current audited
financial statement (Balance Sheet and Statement of Operations, including the auditor’s opinion,
and Reinsurance Provisions.)
K.AGENT MINIMUM QUALIFICATIONS
All agents submitting proposals for this insurance must meet the following minimum qualifications:
1. The agency must be licensed in Texas.
2.The agency must have insurance for agent’s errors and omissions liability with a limit of at least $1
million per occurrence. A certificate of the agent’s E&O insurance must be included with the
proposal.
3.The agency must have been in business for at least five (5) years.
4.The agency must assign a minimum of one qualified account representative. This representative
must have a minimum of three (3) years of experience in commercial property and liability insurance
lines or hold the C.P.C.U. or A.R.M. designation.
L. AUTHORIZED SIGNATURE
1.All proposal forms must be signed by persons who have legal authority to bind the insurer and
administrator to the services that are proposed.
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Westlake Academy – FY 25/26 Comprehensive Insurance RFP Page 12 of 39
Name of Company: _________________________________________________________
A. M. Best Rating/Size: _________________________________
Insurance Company: Yes No Risk Pool: Yes No
F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION:
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CRIME INSURANCE
A. BACKGROUND INFORMATION
1.No claims since inception of coverage in 2003.
2. Copy of current policy declaration schedule is attached.
B.INSURANCE COVERAGE IS TO INCLUDE THE FOLLOWING:
1.Crime Limits & Coverage Desired:
Single Loss Limit Retention
Employee Theft $ 250,000 $ 2,500
ERISA Fidelity $ 250,000 $ 0
Forgery or Alteration $ 250,000 $ 2,500
On Premises $ 250,000 $ 2,500
In Transit $ 250,000 $ 2,500
Money Orders/Counterfeit $ 250,000 $ 2,500
Computer Fraud $ 250,000 $ 2,500
Program/Restoration Expense $ 100,000 $ 2,500
Funds Transfer Fraud $ 250,000 $ 2,500
Claim Expense $ 5,000 $ 0
2. Include a listing of additional coverages and coverage extensions.
3.Include a listing of exclusions.
C.QUOTED COVERAGE PROVISIONS
1.Coverage Detail
Employee Theft
ERISA Fidelity
Forgery or Alteration
On Premises
In Transit
Money Orders/Counterfeit
Computer Fraud
Program/Restoration Expense
Funds Transfer Fraud
Claim Expense
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WORKERS COMPENSATION INSURANCE
A. BACKGROUND INFORMATION
1.Please contact Purchasing Agent at sgarza@westlaketx.gov for loss runs.
2.Experience Modifier is currently 0.77.
3.Estimated FY 25-26 payroll schedule is below.
4.Estimated number of regular employees is 116 (excluding substitute teachers & part-time coaches.)
B.INSURANCE COVERAGE IS TO INCLUDE THE FOLLOWING:
1.Workers Compensation Limits & Coverage Desired:
Limit Per
Bodily Injury by Accident $ 1,000,000 Accident
Bodily Injury by Disease $ 1,000,000 Policy Limit
Bodily Injury by Disease $ 1,000,000 Employee
2.Estimated FY 25-26 payroll is as follows:
Payroll Code Annual Amount Employees
8868 $ 11,787,821 104 (does not include substitute teachers)
8810 $ 377,710 6
9101 $ 192,641 3
Total Estimated Payroll:$12,358,172.18 113
3.Please include “Others States Coverage” where applicable, as an additional endorsement.
4. Please include “Terrorism Risk” as an additional endorsement.
5.Include a listing of additional coverage, extensions, and exclusions.
6.Include a Blanket Waiver of Subrogation.
C.QUOTED COVERAGE PROVISIONS
1.Does coverage utilize a specific provider network?Yes No
If yes, please provide details.
D.QUOTATION
1.Workers Compensation Insurance Quote (Attach complete coverage information)
Annual Premium (Period 07/01/2025 to 06/30/2026): $________________________________
2. Alternate Workers Compensation Insurance Quote (Attach complete coverage information)
Annual Premium (Period 07/01/2025 to 06/30/2026): $________________________________
x
15,593
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INTERNATIONAL TRAVEL LIABILITY INSURANCE
A. BACKGROUND INFORMATION
1.No claims since inception of coverage in 2015.
2.Coverage is for employees engaged in overseas travel, and no countries excluded.
3.Coverage should include Medical Assistance, Personal Assistance, and Travel Assistance for
employees and students, based on 50 participants per year.
B. DESIRED INSURANCE COVERAGE IS TO INCLUDE THE FOLLOWING:
1. Benefits Limit Per Aggregate
Medical Expense Limit $ 50,000 Person $ 50,000
Dental Treatment $ 250 Tooth $ 500
Room and Board Average semi-private room rate
ICU Room and Board Charges Twice the semi-private room rate
Treatment of Pregnancy Treated as any other medical condition
Preexisting Conditions Treated as any other medical condition
Chiropractic Care $ 35 Visit $ 350
Emergency Medical Evacuation 100% Expenses
Repatriation of Remains 100% Expenses
Chaperone Replacement $ 2,000
Accidental Death & Dismemberment $ 10,000 Student
Accidental Death & Dismemberment $ 50,000 Faculty
Kidnap/Ransom $ 100,000 Event $ 100,000
Aggregate Limit $ 250,000 Benefit Max
2.All coverage is $0 deductible with 100% coinsurance.
3.Include a listing of additional coverages, coverage extensions, and AD&D schedule.
4.Include a listing of exclusions.
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CYBER RISK LIABILITY
A. BACKGROUND INFORMATION
1.Coverage is intended to supplement Cyber Liability Coverage(s) that are contained within other
policies quoted, or offer additional coverage excluded within those policies.
2.This should be offered as a stand-alone policy which may be accepted or rejected by Westlake
Academy, without affecting the pricing of other policies.
3.Coverage should include the following or the most equivalent limits and deductible available:
B.INSURANCE COVERAGE IS TO INCLUDE THE FOLLOWING:
1.Liability Limits & Coverage:
Limit Deductible
Liability Coverages
Networks and information security $ 1,000,000 $10,000
Communications and media $ 1,000,000 $10,000
Regulatory defense expenses $ 500,000 $10,000
1st Party coverage
Crisis Management event expenses $ 500,000 $10,000
Security Breach remediation and $ 500,000 $10,000
notification expenses
E-commerce extortion $ 500,000 $10,000
Business interruption and additional $ 500,000 24 Hours
Expenses
2.Include coverage descriptions of each insuring agreement
3.Include a listing of additional coverages, coverage extensions, and exclusions.
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D. QUOTATION
1.Cyber liability Insurance Quote (Attach complete coverage information)
Annual Premium (Period 07/01/2025 to 06/30/2026): $________________________________
2. Alternate Cyber liability Insurance Quote (Attach complete coverage information)
Annual Premium (Period 07/01/2025 to 06/30/2026): $________________________________
E. INSURANCE COMPANY/RISK POOL INFORMATION
Name of Company: _________________________________________________________
A. M. Best Rating/Size: _________________________________
Insurance Company: Yes No Risk Pool: Yes No
For Alternate Quote(s):
Name of Company: _________________________________________________________
A. M. Best Rating/Size: _________________________________
Insurance Company: Yes No Risk Pool: Yes No
F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION:
Included In Gen Liab package
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PROPOSAL SUBMITTAL FORMAT
Quotations should be clearly labeled, using the format below. Proposals using an alternate format should
have all quotes clearly labeled by policy type, and include policy limits, details, and cost. All submissions
must include the completed forms below.
1 – Completed Questionnaire
2 - Property Insurance, Fire and Extended Equipment Coverage Quote
3 - General Liability Quote (including D&O, EPLI, EBLI and ELLI coverage)
4 - Automobile Liability & Physical Damage Quote
5 - Umbrella Liability Insurance Quote
6 - Crime Insurance Quote
7 – Workers Compensation Insurance Quote
8 – International Travel Insurance Quote
9 – Student Accident Insurance Quote
10 – Cyber Liability & Cyber Security Insurance Quote
11 - Agent’s Current License, Copy of E&O Insurance Certificate
12 - Completed and signed Felony Conviction Notice Form
13 - Completed and signed Non-Collusion Certification Form
14 - Completed and signed Conflict of Interest Questionnaire Form
15 - Completed and signed W-9 Form
16 - Completed and signed Form 2270
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EXHIBIT “A” - PROPERTY SCHEDULE
1.All buildings are located on 2600 JT Ottinger Road, Westlake TX, 76262. Blanket coverage is
required for buildings and contents.
Building Sq. Footage Valuation Roof Type
#1 22,278 14,221,424 100% concrete tile
#2: 20,260 10,152,372 100% concrete tile
#3 10,492 5,198,895 100% concrete tile
#4: 8,400 6,576,469 80% concrete tile, 20% flat membrane
#5: 8,900 3,380,265 75% seam metal, 25% flat membrane
#6: 8,900 4,089,890 25% concrete tile, 75% flat membrane
#7: 19,820 6,824,200 75% seam metal, 25% flat membrane
#8: 12,500 2,205,000 100% Shingle
#9: 12,500 2,205,000 100% Shingle
Property (Blanket) Limits: $54,853,515
2.Contents:$ 5,021,678
3.Business Income
and Extra Expense:$ 444,000
4.Total Property Limits $60,319,193
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Form W-9 (Rev. 3-2024)Page 2
must obtain your correct taxpayer identification number (TIN), which
may be your social security number (SSN), individual taxpayer
identification number (ITIN), adoption taxpayer identification number
(ATIN), or employer identification number (EIN), to report on an
information return the amount paid to you, or other amount reportable
on an information return. Examples of information returns include, but
are not limited to, the following.
• Form 1099-INT (interest earned or paid).
• Form 1099-DIV (dividends, including those from stocks or mutual
funds).
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds).
• Form 1099-NEC (nonemployee compensation).
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers).
• Form 1099-S (proceeds from real estate transactions).
• Form 1099-K (merchant card and third-party network transactions).
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
and 1098-T (tuition).
• Form 1099-C (canceled debt).
• Form 1099-A (acquisition or abandonment of secured property).
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
Caution: If you don’t return Form W-9 to the requester with a TIN, you
might be subject to backup withholding. See What is backup
withholding, later.
By signing the filled-out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued);
2. Certify that you are not subject to backup withholding; or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee; and
4. Certify to your non-foreign status for purposes of withholding under
chapter 3 or 4 of the Code (if applicable); and
5. Certify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting is correct. See What Is
FATCA Reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other
than Form W-9 to request your TIN, you must use the requester’s form if
it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien;
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States;
• An estate (other than a foreign estate); or
• A domestic trust (as defined in Regulations section 301.7701-7).
Establishing U.S. status for purposes of chapter 3 and chapter 4
withholding. Payments made to foreign persons, including certain
distributions, allocations of income, or transfers of sales proceeds, may
be subject to withholding under chapter 3 or chapter 4 of the Code
(sections 1441–1474). Under those rules, if a Form W-9 or other
certification of non-foreign status has not been received, a withholding
agent, transferee, or partnership (payor) generally applies presumption
rules that may require the payor to withhold applicable tax from the
recipient, owner, transferor, or partner (payee). See Pub. 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities.
The following persons must provide Form W-9 to the payor for
purposes of establishing its non-foreign status.
• In the case of a disregarded entity with a U.S. owner, the U.S. owner
of the disregarded entity and not the disregarded entity.
• In the case of a grantor trust with a U.S. grantor or other U.S. owner,
generally, the U.S. grantor or other U.S. owner of the grantor trust and
not the grantor trust.
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust
and not the beneficiaries of the trust.
See Pub. 515 for more information on providing a Form W-9 or a
certification of non-foreign status to avoid withholding.
Foreign person. If you are a foreign person or the U.S. branch of a
foreign bank that has elected to be treated as a U.S. person (under
Regulations section 1.1441-1(b)(2)(iv) or other applicable section for
chapter 3 or 4 purposes), do not use Form W-9. Instead, use the
appropriate Form W-8 or Form 8233 (see Pub. 515). If you are a
qualified foreign pension fund under Regulations section 1.897(l)-1(d), or
a partnership that is wholly owned by qualified foreign pension funds,
that is treated as a non-foreign person for purposes of section 1445
withholding, do not use Form W-9. Instead, use Form W-8EXP (or other
certification of non-foreign status).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a saving clause. Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items.
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if their stay in the
United States exceeds 5 calendar years. However, paragraph 2 of the
first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the
provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
Protocol) and is relying on this exception to claim an exemption from tax
on their scholarship or fellowship income would attach to Form W-9 a
statement that includes the information described above to support that
exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS 24% of such
payments. This is called “backup withholding.” Payments that may be
subject to backup withholding include, but are not limited to, interest,
tax-exempt interest, dividends, broker and barter exchange
transactions, rents, royalties, nonemployee pay, payments made in
settlement of payment card and third-party network transactions, and
certain payments from fishing boat operators. Real estate transactions
are not subject to backup withholding.
You will not be subject to backup withholding on payments you receive
if you give the requester your correct TIN, make the proper certifications,
and report all your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester;
2. You do not certify your TIN when required (see the instructions for
Part II for details);
3. The IRS tells the requester that you furnished an incorrect TIN;
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only); or
5. You do not certify to the requester that you are not subject to
backup withholding, as described in item 4 under “By signing the filled-
out form” above (for reportable interest and dividend accounts opened
after 1983 only).
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Form W-9 (Rev. 3-2024)Page 3
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the
Requester of Form W-9 for more information.
See also Establishing U.S. status for purposes of chapter 3 and
chapter 4 withholding, earlier.
What Is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a
participating foreign financial institution to report all U.S. account
holders that are specified U.S. persons. Certain payees are exempt from
FATCA reporting. See Exemption from FATCA reporting code, later, and
the Instructions for the Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you are
no longer tax exempt. In addition, you must furnish a new Form W-9 if
the name or TIN changes for the account, for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
•Individual. Generally, enter the name shown on your tax return. If you
have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note for ITIN applicant: Enter your individual name as it was entered
on your Form W-7 application, line 1a. This should also be the same as
the name you entered on the Form 1040 you filed with your application.
•Sole proprietor. Enter your individual name as shown on your Form
1040 on line 1. Enter your business, trade, or “doing business as” (DBA)
name on line 2.
•Partnership, C corporation, S corporation, or LLC, other than a
disregarded entity. Enter the entity’s name as shown on the entity’s tax
return on line 1 and any business, trade, or DBA name on line 2.
•Other entities. Enter your name as shown on required U.S. federal tax
documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. Enter any business,
trade, or DBA name on line 2.
•Disregarded entity. In general, a business entity that has a single
owner, including an LLC, and is not a corporation, is disregarded as an
entity separate from its owner (a disregarded entity). See Regulations
section 301.7701-2(c)(2). A disregarded entity should check the
appropriate box for the tax classification of its owner. Enter the owner’s
name on line 1. The name of the owner entered on line 1 should never
be a disregarded entity. The name on line 1 should be the name shown
on the income tax return on which the income should be reported. For
example, if a foreign LLC that is treated as a disregarded entity for U.S.
federal tax purposes has a single owner that is a U.S. person, the U.S.
owner’s name is required to be provided on line 1. If the direct owner of
the entity is also a disregarded entity, enter the first owner that is not
disregarded for federal tax purposes. Enter the disregarded entity’s
name on line 2. If the owner of the disregarded entity is a foreign person,
the owner must complete an appropriate Form W-8 instead of a Form
W-9. This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded
entity name, enter it on line 2.
Line 3a
Check the appropriate box on line 3a for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3a.
IF the entity/individual on line 1
is a(n) . . .
THEN check the box for . . .
• Corporation Corporation.
• Individual or
• Sole proprietorship
Individual/sole proprietor.
• LLC classified as a partnership
for U.S. federal tax purposes or
• LLC that has filed Form 8832 or
2553 electing to be taxed as a
corporation
Limited liability company and
enter the appropriate tax
classification:
P = Partnership,
C = C corporation, or
S = S corporation.
• Partnership Partnership.
• Trust/estate Trust/estate.
Line 3b
Check this box if you are a partnership (including an LLC classified as a
partnership for U.S. federal tax purposes), trust, or estate that has any
foreign partners, owners, or beneficiaries, and you are providing this
form to a partnership, trust, or estate, in which you have an ownership
interest. You must check the box on line 3b if you receive a Form W-8
(or documentary evidence) from any partner, owner, or beneficiary
establishing foreign status or if you receive a Form W-9 from any
partner, owner, or beneficiary that has checked the box on line 3b.
Note: A partnership that provides a Form W-9 and checks box 3b may
be required to complete Schedules K-2 and K-3 (Form 1065). For more
information, see the Partnership Instructions for Schedules K-2 and K-3
(Form 1065).
If you are required to complete line 3b but fail to do so, you may not
receive the information necessary to file a correct information return with
the IRS or furnish a correct payee statement to your partners or
beneficiaries. See, for example, sections 6698, 6722, and 6724 for
penalties that may apply.
Line 4 Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
• Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
• Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third-party network transactions.
• Corporations are not exempt from backup withholding with respect to
attorneys’ fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space on line 4.
1—An organization exempt from tax under section 501(a), any IRA, or
a custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2).
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Form W-9 (Rev. 3-2024)Page 4
2—The United States or any of its agencies or instrumentalities.
3—A state, the District of Columbia, a U.S. commonwealth or territory,
or any of their political subdivisions or instrumentalities.
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities.
5—A corporation.
6—A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
territory.
7—A futures commission merchant registered with the Commodity
Futures Trading Commission.
8—A real estate investment trust.
9—An entity registered at all times during the tax year under the
Investment Company Act of 1940.
10—A common trust fund operated by a bank under section 584(a).
11—A financial institution as defined under section 581.
12—A middleman known in the investment community as a nominee or
custodian.
13—A trust exempt from tax under section 664 or described in section
4947.
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 13.
IF the payment is for . . .THEN the payment is exempt
for . . .
• Interest and dividend payments All exempt payees except
for 7.
• Broker transactions Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
• Barter exchange transactions
and patronage dividends
Exempt payees 1 through 4.
• Payments over $600 required to
be reported and direct sales over
$5,0001
Generally, exempt payees
1 through 5.2
• Payments made in settlement of
payment card or third-party
network transactions
Exempt payees 1 through 4.
1 See Form 1099-MISC, Miscellaneous Information, and its instructions.
2 However, the following payments made to a corporation and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys’ fees, gross
proceeds paid to an attorney reportable under section 6045(f), and
payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain if the financial institution is
subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with “Not Applicable” (or
any similar indication) entered on the line for a FATCA exemption code.
A—An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37).
B—The United States or any of its agencies or instrumentalities.
C—A state, the District of Columbia, a U.S. commonwealth or
territory, or any of their political subdivisions or instrumentalities.
D—A corporation the stock of which is regularly traded on one or
more established securities markets, as described in Regulations
section 1.1472-1(c)(1)(i).
E—A corporation that is a member of the same expanded affiliated
group as a corporation described in Regulations section 1.1472-1(c)(1)(i).
F—A dealer in securities, commodities, or derivative financial
instruments (including notional principal contracts, futures, forwards,
and options) that is registered as such under the laws of the United
States or any state.
G—A real estate investment trust.
H—A regulated investment company as defined in section 851 or an
entity registered at all times during the tax year under the Investment
Company Act of 1940.
I—A common trust fund as defined in section 584(a).
J—A bank as defined in section 581.
K—A broker.
L—A trust exempt from tax under section 664 or described in section
4947(a)(1).
M—A tax-exempt trust under a section 403(b) plan or section 457(g)
plan.
Note: You may wish to consult with the financial institution requesting
this form to determine whether the FATCA code and/or exempt payee
code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number).
This is where the requester of this Form W-9 will mail your information
returns. If this address differs from the one the requester already has on
file, enter “NEW” at the top. If a new address is provided, there is still a
chance the old address will be used until the payor changes your
address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have, and are not eligible to get, an SSN, your TIN is your
IRS ITIN. Enter it in the entry space for the Social security number. If you
do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN.
If you are a single-member LLC that is disregarded as an entity
separate from its owner, enter the owner’s SSN (or EIN, if the owner has
one). If the LLC is classified as a corporation or partnership, enter the
entity’s EIN.
Note: See What Name and Number To Give the Requester, later, for
further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS-5, Application for a Social Security
Card, from your local SSA office or get this form online at
www.SSA.gov. You may also get this form by calling 800-772-1213. Use
Form W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN
online by accessing the IRS website at www.irs.gov/EIN. Go to
www.irs.gov/Forms to view, download, or print Form W-7 and/or Form
SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and
have Form W-7 and/or Form SS-4 mailed to you within 15 business
days.
If you are asked to complete Form W-9 but do not have a TIN, apply
for a TIN and enter “Applied For” in the space for the TIN, sign and date
the form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily tradable
instruments, you will generally have 60 days to get a TIN and give it to
the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to other types of payments.
You will be subject to backup withholding on all such payments until
you provide your TIN to the requester.
Note: Entering “Applied For” means that you have already applied for a
TIN or that you intend to apply for one soon. See also Establishing U.S.
status for purposes of chapter 3 and chapter 4 withholding, earlier, for
when you may instead be subject to withholding under chapter 3 or 4 of
the Code.
Caution: A disregarded U.S. entity that has a foreign owner must use
the appropriate Form W-8.
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Form W-9 (Rev. 3-2024)Page 5
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on line 1 must sign. Exempt payees, see Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
1. Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. “Other payments” include
payments made in the course of the requester’s trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments made in settlement of payment
card and third-party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:Give name and SSN of:
1. Individual The individual
2. Two or more individuals (joint account)
other than an account maintained by
an FFI
The actual owner of the account or,
if combined funds, the first individual
on the account1
3. Two or more U.S. persons
(joint account maintained by an FFI)
Each holder of the account
4. Custodial account of a minor
(Uniform Gift to Minors Act)
The minor2
5. a. The usual revocable savings trust
(grantor is also trustee)
The grantor-trustee1
b. So-called trust account that is not
a legal or valid trust under state law
The actual owner1
6. Sole proprietorship or disregarded
entity owned by an individual
The owner3
7. Grantor trust filing under Optional
Filing Method 1 (see Regulations
section 1.671-4(b)(2)(i)(A))**
The grantor*
For this type of account:Give name and EIN of:
8. Disregarded entity not owned by an
individual
The owner
9. A valid trust, estate, or pension trust Legal entity4
10. Corporation or LLC electing corporate
status on Form 8832 or Form 2553
The corporation
11. Association, club, religious, charitable,
educational, or other tax-exempt
organization
The organization
12. Partnership or multi-member LLC The partnership
13. A broker or registered nominee The broker or nominee
14. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or prison)
that receives agricultural program
payments
The public entity
15. Grantor trust filing Form 1041 or
under the Optional Filing Method 2,
requiring Form 1099 (see Regulations
section 1.671-4(b)(2)(i)(B))**
The trust
1 List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN, that person’s number
must be furnished.
2 Circle the minor’s name and furnish the minor’s SSN.
3 You must show your individual name on line 1, and enter your business
or DBA name, if any, on line 2. You may use either your SSN or EIN (if
you have one), but the IRS encourages you to use your SSN.
4 List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.)
*Note: The grantor must also provide a Form W-9 to the trustee of the
trust.
** For more information on optional filing methods for grantor trusts, see
the Instructions for Form 1041.
Note: If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information,
such as your name, SSN, or other identifying information, without your
permission to commit fraud or other crimes. An identity thief may use
your SSN to get a job or may file a tax return using your SSN to receive
a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax return preparer.
If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity, or a questionable credit report, contact the IRS
Identity Theft Hotline at 800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
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Form W-9 (Rev. 3-2024)Page 6
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems that
have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 877-777-4778 or TTY/TDD
800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint. You can
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.IdentityTheft.gov
and Pub. 5027.
Go to www.irs.gov/IdentityTheft to learn more about identity theft and
how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your
correct TIN to persons (including federal agencies) who are required to
file information returns with the IRS to report interest, dividends, or
certain other income paid to you; mortgage interest you paid; the
acquisition or abandonment of secured property; the cancellation of
debt; or contributions you made to an IRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice for civil and criminal litigation and to cities, states, the District of
Columbia, and U.S. commonwealths and territories for use in
administering their laws. The information may also be disclosed to other
countries under a treaty, to federal and state agencies to enforce civil
and criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism. You must provide your TIN whether or not
you are required to file a tax return. Under section 3406, payors must
generally withhold a percentage of taxable interest, dividends, and
certain other payments to a payee who does not give a TIN to the payor.
Certain penalties may also apply for providing false or fraudulent
information.
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BINDING AUTHORIZATION
BOX INSURANCE AGENCY, LLC | WESTLAKE ACADEMY 3 | 4
INSURED
WESTLAKE ACADEMY
As presented (all lines)
With changes noted below
1.
2.
3.
4.
5.
SUBJECTIVITIES
•Signed ACORDS
•Signed SOV
•Signed TRIAs
•Signed Supplementals
PRINT NAME TITLE
SIGNATURE DATE
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